Influence of Not-for-Profit Hospital Ownership Type on Community Benefit and Charity Care.

Non-profit hospitals are expected to provide charity care and other community benefits to adjust their tax exemption status. Using the Medicare Hospital Cost Report, American Hospital Association Annual Survey, and the American Community Survey datasets, we examined if church-affiliated hospitals spent more on charity care and community benefit. For this analysis, we defined five main categories of community benefits were measured: total community benefit; charity care; Medicaid shortfall; unreimbursed other means-tested services; and the total of unreimbursed education and unfunded research. Multiple regression was used to examine the effect of church ownership, controlling for other factors, on the level of community benefit in 2644 general acute care non-profit hospitals. Descriptive analyses and multiple regression were used to show the relationship between the provision of community benefits and church affiliation including Catholic (CH), other church-affiliated hospitals (OCAH), and non-church affiliated hospitals (NCAH). The non-profit hospital on average spent 6.5% of its total expenses on community benefits. NCAH spent 6.09%, CH spent 7.5%, and OCAH spent 9.4%. Non-profits spent 2.8% of their total expenses on charity care, with the highest charity care spending for OCAH (5.2%), followed by CH (3.9%), and NCAH (2.4%). Regression results showed that CH and OCAH, on average, spent 1.08% and 2.16% more on community benefits than NCAHs. In addition, CH and OCAH spent more on other categories of community benefits except for education and research. Church-affiliated hospitals spend more on community benefits and charity care than non-church affiliated nonprofit hospitals.

Changes in insurance status and access to care in an integrated safety net healthcare system.

This paper focuses on a cohort of uninsured patients that have accessed outpatient healthcare services in an urban safety net, evaluating the degree to which they switch insurance status and the impact this switching has on access to care. The results indicate that in an integrated safety net system, there is a high frequency of insurance status switching by the uninsured. Uninsured patients who switch to insured status were found to be more likely to visit specialty points of care and less likely to visit urgent points of care than the continuously uninsured. It is well documented that insurance coverage and continuity of care influence health status. Continuity of insurance coverage also has an impact on access to care for those receiving services within a safety net healthcare system.

Presence of de novo mutations in autosomal dominant polycystic kidney disease patients without family history.

BACKGROUND: At the University of Colorado Health Sciences Center, on detailed questioning, approximately 10% of patients with autosomal dominant polycystic kidney disease (ADPKD) gave no family history of ADPKD. There are several explanations for this observation, including occurrence of a de novo pathogenic sequence variant or extreme phenotypic variability. To confirm de novo sequence variants, we have undertaken clinical and genetic screening of affected offspring and their parents. STUDY DESIGN: Case series. SETTING & PARTICIPANTS: 24 patients with a well-documented ADPKD phenotype and no family history of polycystic kidney disease (PKD) and both parents of each patient. OUTCOME: Presence or absence of PKD1 or PKD2 pathogenic sequence variants in parents of affected offspring. MEASUREMENTS: Abdominal ultrasound of affected offspring and their parents for ADPKD diagnosis. Parentage testing by genotyping. Complete screening of PKD1 and PKD2 genes by using genomic DNA from affected offspring; analysis of genomic DNA from both parents to confirm the absence or presence of all DNA variants found. RESULTS: A positive diagnosis of ADPKD by means of ultrasound or genetic screening was made in 1 parent of 4 patients (17%). No PKD1 or PKD2 pathogenic sequence variants were identified in 10 patients (42%), whereas possible pathological DNA variants were identified in 4 patients (17%) and 1 of their respective parents. Parentage was confirmed in the remaining 6 patients (25%), and de novo sequence variants were documented. LIMITATIONS: Size of patient group. No direct examination of RNA. CONCLUSION: Causes other than de novo pathogenic sequence variants may explain the negative family history of ADPKD in certain families.

Separate or United: The Safety Net in the Era of Health Care Integration.

Rapid and significant transformation is occurring within the private sector of the health care system with consolidation, integration and the formation of new organizational structures such as Accountable Care Organizations. However, the safety-net systems upon which many patients rely, have remained largely in silos. To focus a spotlight on this issue at a community level we have compared the safety net in Alameda County, California and Denver, Colorado, the former with a safety net largely in silos and the latter an integrated safety net. We have discussed the policy implications and have delineated some of the levers that could be utilized to facilitate greater safety-net integration.

Observations of residents' work activities for 24 consecutive hours: implications for workflow redesign.

PURPOSE: To examine resident workflow as part of an institutional approach to redesigning the processes of health care delivery. METHOD: In 2003 the authors observed the workflows for 24 hours of seven residents who were at various levels of training (two each from the internal medicine, pediatrics, and obstetrics and gynecology programs, and one from general surgery) at Denver Health Medical Center, an urban, public teaching hospital. RESULTS: Although the residents spent varying proportions of their time in various activities, all had extremely fragmented workflows as they engaged in from 5.0 to 11.3 different activities per hour of nonsleeping time, many of which required only minutes to complete. All residents experienced frequent interruptions and changes in focus. The internal medicine and surgery residents spent large amounts of time traveling, covering three and six miles, respectively, during their 24-hour shifts. Three of the residents slept between one-quarter and one-third of their time on duty (one without any interruption). CONCLUSIONS: The authors suggest that fragmented workflow exists in all residency programs and that applying the same work limitations to all residents in all training programs (to reduce fatigue-related errors) may be overly restrictive. Improving these processes of care will be difficult and will likely require analytic skills and knowledge of systems engineering that most physicians do not have.

Closing the Health Care Gap in Communities: A Safety Net System Approach.

The goal of U.S. health care should be good health for every American. This daunting goal will require closing the health care gap in communities with a particular focus on the most vulnerable populations and the safety net institutions that disproportionately serve these communities. This Commentary describes Denver Health's (DH's) two-pronged approach to achieving this goal: (1) creating an integrated system that focuses on the needs of vulnerable populations, and (2) creating an approach for financial viability, quality of care, and employee engagement. The implementation and outcomes of this approach at DH are described to provide a replicable model. An integrated delivery system serving vulnerable populations should go beyond the traditional components found in most integrated health systems and include components such as mental health services, school-based clinics, and correctional health care, which address the unique and important needs of, and points of access for, vulnerable populations. In addition, the demands that a safety net system experiences from an open-door policy on access and revenue require a disciplined approach to cost, quality of care, and employee engagement. For this, DH chose Lean, which focuses on reducing waste to respect the patients and employees within its health system, as well as all citizens. DH's Lean effort produced almost $195 million of financial benefit, impressive clinical outcomes, and high employee engagement. If this two-pronged approach were widely adopted, health systems across the United States would improve their chances of giving better care at costs they can afford for every person in society.

The effect of automated alerts on provider ordering behavior in an outpatient setting.

BACKGROUND: Computerized order entry systems have the potential to prevent medication errors and decrease adverse drug events with the use of clinical-decision support systems presenting alerts to providers. Despite the large volume of medications prescribed in the outpatient setting, few studies have assessed the impact of automated alerts on medication errors related to drug-laboratory interactions in an outpatient primary-care setting. METHODS AND FINDINGS: A primary-care clinic in an integrated safety net institution was the setting for the study. In collaboration with commercial information technology vendors, rules were developed to address a set of drug-laboratory interactions. All patients seen in the clinic during the study period were eligible for the intervention. As providers ordered medications on a computer, an alert was displayed if a relevant drug-laboratory interaction existed. Comparisons were made between baseline and postintervention time periods. Provider ordering behavior was monitored focusing on the number of medication orders not completed and the number of rule-associated laboratory test orders initiated after alert display. Adverse drug events were assessed by doing a random sample of chart reviews using the Naranjo scoring scale. The rule processed 16,291 times during the study period on all possible medication orders: 7,017 during the pre-intervention period and 9,274 during the postintervention period. During the postintervention period, an alert was displayed for 11.8% (1,093 out of 9,274) of the times the rule processed, with 5.6% for only "missing laboratory values," 6.0% for only "abnormal laboratory values," and 0.2% for both types of alerts. Focusing on 18 high-volume and high-risk medications revealed a significant increase in the percentage of time the provider stopped the ordering process and did not complete the medication order when an alert for an abnormal rule-associated laboratory result was displayed (5.6% vs. 10.9%, p = 0.03, Generalized Estimating Equations test). The provider also increased ordering of the rule-associated laboratory test when an alert was displayed (39% at baseline vs. 51% during post intervention, p < 0.001). There was a non-statistically significant difference towards less "definite" or "probable" adverse drug events defined by Naranjo scoring (10.3% at baseline vs. 4.3% during postintervention, p = 0.23). CONCLUSION: Providers will adhere to alerts and will use this information to improve patient care. Specifically, in response to drug-laboratory interaction alerts, providers will significantly increase the ordering of appropriate laboratory tests. There may be a concomitant change in adverse drug events that would require a larger study to confirm. Implementation of rules technology to prevent medication errors could be an effective tool for reducing medication errors in an outpatient setting.

Using computerized clinical decision support for latent tuberculosis infection screening.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) has published guidelines recommending screening high-risk groups for latent tuberculosis infection (LTBI). The goal of this study was to determine the impact of computerized clinical decision support and guided web-based documentation on screening rates for LTBI. DESIGN: Nonrandomized, prospective, intervention study. SETTING AND PARTICIPANTS: Participants were 8463 patients seen at two primary care, outpatient, public community health center clinics in late 2002 and early 2003. INTERVENTION: The CDC's LTBI guidelines were encoded into a computerized clinical decision support system that provided an alert recommending further assessment of LTBI risk if certain guideline criteria were met (birth in a high-risk TB country and aged <40). A guided web-based documentation tool was provided to facilitate appropriate adherence to the LTBI screening guideline and to promote accurate documentation and evaluation. Baseline data were collected for 15 weeks and study-phase data were collected for 12 weeks. MAIN OUTCOME MEASURES: Appropriate LTBI screening according to CDC guidelines based on chart review. RESULTS: Among 4135 patients registering during the post-intervention phase, 73% had at least one CDC-defined risk factor, and 610 met the alert criteria (birth in a high-risk TB country and aged <40 years) for potential screening for LTBI. Adherence with the LTBI screening guideline improved significantly from 8.9% at baseline to 25.2% during the study phase (183% increase, p < 0.001). CONCLUSIONS: This study demonstrated that computerized, clinical decision support using alerts and guided web-based documentation increased screening of high-risk patients for LTBI. This type of technology could lead to an improvement in LTBI screening in the United States and also holds promise for improved care for other preventive and chronic conditions.

Prevalence of psychiatric disorders and costs of care among adult enrollees in a Medicaid HMO.

OBJECTIVE: Little is known about how psychiatric disorders affect health care costs in Medicaid programs. The prevalence of psychiatric disorders and costs of care for members of a Medicaid health maintenance organization (HMO) who had psychiatric disorders were examined. METHODS: A cross-sectional, observational analysis of adult Medicaid beneficiaries over a 12-month period was conducted by using data from a health plan that has both an HMO and a behavioral health carve-out. Claims data were analyzed for 6,500 adults who were eligible for services in both plans and who received medical or behavioral health services during calendar year 2000. RESULTS: Thirty-nine percent of the 6,500 adults had a psychiatric diagnosis. Of this subset, 67.2 percent had received no specialty mental health care in the previous year. The presence of any psychiatric diagnosis significantly increased total health care costs by a factor of 2.24 ($6,995 compared with $3,121 for persons with no psychiatric diagnosis) and costs to the medical plan by a factor of 1.77 ($4,690 compared with $2,649). For beneficiaries with bipolar or psychotic diagnoses, higher health plan costs were due predominately to increases in pharmacy and specialty mental health costs. In contrast, higher costs for beneficiaries with depression, anxiety, or substance use diagnoses were attributable to greater use of general medical services. CONCLUSIONS: An analysis of claims data showed that adult Medicaid beneficiaries have exceptionally high rates of comorbid psychiatric conditions, which were associated with significantly higher medical and pharmaceutical costs. The high cost of these beneficiaries to the medical plan has policy implications in terms of the importance of addressing mental health issues in Medicaid general medical populations.

Denver Health: a model for the integration of a public hospital and community health centers.

Two major pillars of the United States' safety net system are urban public hospitals and community health centers. Their common mission is to care for the uninsured and other vulnerable populations. However, in most communities these important components of the safety net remain organizationally and functionally separate, which inhibits the continuum of care and creates substantial inefficiencies. Denver Health is a long-standing vertically and horizontally integrated system for vulnerable populations. The integration benefits the patient and the system and serves as a model for the U.S. safety net. This paper outlines the benefits of integration to the patient, provider, and health system, using data from the National Association of Public Hospitals and Health Systems, the Bureau of Primary Health Care, and Denver Health.

The fall: aligning the best care with standards of care at the end of life.

When her mother is hurt, a health care executive finds that the standardized care she championed isn't always appropriate.

For many patients who use large amounts of health care services, the need is intense yet temporary.

Patients who accumulate multiple emergency department visits and hospital admissions, known as super-utilizers, have become the focus of policy initiatives aimed at preventing such costly use of the health care system through less expensive community- and primary care-based interventions. We conducted cross-sectional and longitudinal analyses of 4,774 publicly insured or uninsured super-utilizers in an urban safety-net integrated delivery system for the period May 1, 2011-April 30, 2013. Our analysis found that consistently 3 percent of adult patients met super-utilizer criteria and accounted for 30 percent of adult charges. Fewer than half of super-utilizers identified as such on May 1, 2011, remained in the category seven months later, and only 28 percent remained at the end of a year. This finding has important implications for program design and for policy makers because previous studies may have obscured this instability at the individual level. Our study also identified clinically relevant subgroups amenable to different interventions, along with their per capita utilization and costs before and after being identified as super-utilizers. Future solutions include improving predictive modeling to identify individuals likely to experience sustained levels of avoidable utilization, better classifying subgroups for whom interventions are needed, and implementing stronger program evaluation designs.

Evaluating patient compliance with nurse advice line recommendations and the impact on healthcare costs.

OBJECTIVE: To explore the effect of telephone triage and advice lines in uninsured and managed care populations served by a safety net system and to document the relationship between the patient's initial plan for healthcare, the nurse recommendation, and the patient's subsequent healthcare action. STUDY DESIGN: Prospective telephone survey. PATIENTS AND METHODS: Of 1538 calls to a nurse advice line in a 28-day period, 710 (46%) callers were selected to be surveyed. Of those, 278 (39%) were surveyed by telephone within 7 days of their call to assess patient compliance with recommendations, the patient's actual healthcare actions, and their satisfaction with the service. RESULTS: Patients' reported actions were classified as either (1) home care (46%), (2) clinic visit (27%), or (3) hospital visit (27%). Seventy percent of patients complied with nurse advice line recommendations. Most patient actions (68%) differed from their original healthcare plan, with many (46%) choosing a lower intensity of care. Changes from patients' original healthcare plans had a potential annual net savings of $322 249. CONCLUSION: The simple act of calling a nurse triage and advice line corresponds with a change in the reported actions of uninsured and managed care patients and a potential reduction in costs to the safety net system providing their healthcare.